New Regulations for Foods Offered to School Children in Chile: Barriers to Implementation

Two sequential literature reviews were conducted, one in Spanish and one in English, using Proquest, EbscoHost, Chile's Health Ministry website and PubMed. Search criteria included key words of "Chile," "La Composición Nutricional de los Alimentos y Su Publicidad," "food regulation," "children," "obesity," and "nutrition." These words were used for articles published in English and in Spanish. A total of 3,789 were identified, but only 13 were included as part of this review. These papers represented: 13 studies, 3 policy papers, and a copy of law 20.606 was also retrieved. Criteria for selection included: 17 articles published after the date of 1988, and articles relevant to the topic of student nutrition. For the purpose of the paper, “students” refers to both school-age children and adolescents (including university students).

Seven articles in Spanish and 10 articles in English were identified for the narrative review. The overarching theme of these articles showed that modernization in Chile has resulted in more unhealthy food options being integrated into children's diet. Results from the literature review shows that unhealthy food options are readily available to children in school kiosks.^{6 , 10} The study concluded that the food products that the students bought with their money were generally packaged products with much sugar, fat, and salt; these foods have a high energetic density and are often more appealing when they are available to students in schools.^{10 , 11} For example, 99% of the children studied said they had money to buy food products at their school, and 90% of them chose to buy unhealthful items (68.1% bought sweet or salty foods, 17.2% sugary soda drinks, and 3.7% fast food).¹¹ These food options can result in health problems. Rates of children being obese or overweight have increased dramatically over the years^{2, 8}.Some articles have discussed the importance of the regulation of food marketing to children and how to monitor the enforcement of these foods.^{8 , 9} The study by Bustos advocated for incorporating strategies to promote healthful food options inside educational facilities. One study found an increase in 6 year-old children's rates of overweight and obesity between 1986 and 2000. Boys rates increased by 12% (to 26%) and girls, by 14% (to 27%)^{2, 8}.This article discusses the importance of the regulation of food marketing to children, what and how to regulate food, and how to monitor the enforcement of these food laws^{8, 9}.

Chilean health food law 20.606 addresses regulating certain unhealthy food items, advertising ingredients properly on nutrition labels, bans certain foods high in salt, sugar or fat from being sold in the store, and prohibits food items to be sold with toys, or incentives to purchase these items.⁸ Despite this law, previous studies such as these demonstrated that unhealthful food options continue to be readily available for students to purchase in schools. The challenges in successfully integrating food regulation policy are due to a number of factors in Chile⁸ Chile, which is considered a developing country, currently has limited resources to successfully track the law’s implementation. Food restrictions in one country could potentially direct advertisers to relocate their marketing elsewhere^{8, 12}.Previous studies conclude that citizens, particularly the parents of the students, should have a larger role in enforcing healthier foods in schools. One concludes that monitoring of food regulation should be a responsibility of both the government and the people¹³

A narrative literature review of the food regulation policies for childhood nutrition in Chilean schools and barriers to their implementation was conducted, using Pub Med, EbscoHost, and Proquest. A mix-method descriptive, qualitative study was conducted in the Valparaíso Region of Chile to examine knowledge of new school food regulations and barriers to its implementation. Qualitative content analysis techniques were conducted and combined with descriptive analysis. Visual observations of the food kiosks were also made.

A sample of twelve randomly-selected school food kiosk owners in the Valparaiso region with a population of approximately 300,000 were administered a survey and also participated in an interview consisting of 4 open-ended questions. This investigation was carried out by the lead investigator in 12 schools: 4 private schools, 3 municipal schools, 1 state university, 2 private universities, and 2 professional private institutes, all located in the Valparaíso region of Chile. Before administering the survey and interview, the investigator obtained written which described the objective of the study to the participants. It was explained to all of the participants that their participation was voluntary and anonymous. All participants were over the age of 18 years and signed the consent forms, except for 2 who gave their consent orally. The study was approved by the SIT Institutional Review Board (IRB) as well as the Electronic Homewood Insitutional Review Board (eHIRB).

One of the team members (DP) served as a local bilingual interpreter and helped with some of the translations of Spanish responses into English. Another team member (MV) helped explain the study to participants so they could better understand their role in the investigation. The investigator then distributed the survey, which was paper and pen, followed by the interview. Survey questions were related to types of food available in the kiosk, food preferences of the students, and their understanding of the new food law.

The investigator also made observations about the food options inside the kiosks . Specific permission to take photos of the kiosks was obtained from the participants.

The questions in the first part of the survey included 6 open-ended questions and 2 multiple-choice structured questions. Based on the response to the question, "Have you heard of the Chilean law, the Nutritional Food Composition Law and Its Publicity, also called Law Super8? (Yes/No)," the participants continued to respond to a cluster of questions in relation to their given response. Some items were expanded upon in the interview.

Also included were the responses to the interview questions. Specifically, each participant responded to 4 open-ended questions pertaining to the food regulation law 20.606 and the food items sold in their kiosk.

Content analysis and descriptive methods from both the open-ended survey and the interview items were used to identify trends in food items sold, and to determine the depth of understanding kiosk owners have regarding the specific food law, "La Composición Nutricional de los Alimentos y Su Publicidad." Themes were determined by 2 trained reviewers until 100% agreement was reached. One reviewer (DP), a certified Spanish translator, also confirmed the Spanish translations of the survey and interview questions.

Responses to each of the following open-ended questions from the survey were transcribed verbatim, then collapsed and tallied: "What kinds of food do you sell in your store?," "What is the most popular food item in your store, and why do you think?," "What is your favorite thing to sell in the store? Why?," "What is the age of the majority of your customers, and what kinds of foods do they like to buy the most?," "How is your kiosk different from others?," "Do you like the location of your kiosk? Why or why not?," "Are you in agreement with this law? Why or why not?, " "Do you think this law is a benefit to your business and/or customers? Why or why not?," "Why do you carry lactose and fruit? What is the benefit to having lactose and fruit in your store?," "Why do you not carry fruit and lactose?," and "Would you be interested in incorporating fruit and lactose in your store? Why or why not?"

The interviewer also translated the responses verbatim from the interview to each of the following questions..."Do you think this law is important and necessary? Why or why not? Do you think there has been a change in the food sold in educational facilities between the past and the present? What are these changes, if any? Please name the products in your kiosk that students like to purchase the most."Pattern recognition was employed to detect common themes. Pattern recognition implies seeing something over and over again in one case or across a selection of cases.⁷ Results were crosschecked for inter-rater reliability. Themes were developed for the open-ended questions from the survey and for the 4 interview questions. All completed surveys and interviews were kept in a secured, locked cabinet.

Visual observations were also made of food items sold at each participating school’s food kiosk to confirm the owners’ self-reported information. Photos were also taken at that time (see Figure 1 for examples).

Figure 1.Visual observations were also made of food items sold at each participating school’s food kiosk to confirm the owners’ self-reported information.

Results from the close-ended, multiple-choice items of the survey revealed trends among kiosk owners regarding food regulation for students inside of schools. 10 out of 12 participants (83%) had heard of the Chilean law, La Composición Nutricional de los Alimentos y Su Publicidad (20.606). When asked, "What does the law consist of?," 60% of the participants selected, "to promote healthier food options for students," and "regulates the advertisement of unhealthy food in school kiosks." Their responses to, "To what populations is this law targeting?" included "students" and "the general public."

The kiosk owners were then asked, "Are you in agreement with this law?" Half (5 out of the 10 owners who have heard of the law responded that they are in agreement with the law, 2 (20%) answered that they do not agree with the law, and 3 (30%) said that they don't know how they feel about the law. In a different question, "Do you think this law is a benefit to your business and customers?," only the 9 out of the 10 owners who had heard of the law responded to this question (one chose not to respond). 45% percent said, "I don't know," 33% said "It's a benefit," and 22% said "It's not a benefit."

The answers to the open-ended questions were ordered into tables to examine the perceptions and understanding of the participants about the food in their kiosks. Selected responses were used to illustrate thematic elements. Answers to: "What kinds of food do you sell in your store," are shown in Table 1. Trends here are that 7 of the 12 kiosk owners sell a type of sweet item in their kiosk. Specific items listed in their responses included "pie," "cookies," "chocolate," "jello," and "sweets" (candies, gummies, etc.). Only 2 of the owners responded "fruit," and only 2 mentioned lactose products, including yogurt.

Results collected from the interviews were organized into common themes (Table 2). Interview responses showed several patterns related to food items in schools. One trend discovered among participants was the belief that poor eating habits were formed at home. 6 of the 12 participants (50%) directly referred to this in their interviews. Another trend that emerged from the interview responses was that kiosk owners generally believe that food regulation law 20.606 is important and necessary for students. Nine of the 12 participants mentioned that the law has been good for students in terms of developing healthier eating habits. Another trend found from the interviews was that despite the law, students continue to purchase junk food from kiosks. 5 of the 12 participants discussed this trend in their interviews. Some kiosk owners who seemed to have had some understanding regarding the law responded, "I think that they have to have all of the products labeled on the nutritional part outside, like how much fat, salt, how many things it has in it," and "they do not permit junk food here".

The results of the survey and interview demonstrate that school kiosk owners have a general understanding of the food law. When asked to explain why they agreed or disagreed with the law, many owners responded that they "did not know" or "did not have a reason." Examples of the visual observations made of the food items sold at the school kiosks can be seen in photographs 1 and 2. Many items would be categorized as "unhealthful foods." Overall, the photos confirmed the kiosk owners’ responses.